Commercial and Medicaid Shared Savings Program: Year 1 Payment and Reporting Measures Green Mountain Care Board November 21, 2013 11/22/2013 1
Outline Overview of decision points Review of Year 1 Payment and Reporting Measures Discussion of new information since 10/10/2013 Review of Proposal for Evaluation of Reporting Measures Review of proposed Gate and Ladder Methodology Review of recommendations from Core Team 11/22/2013 2
GMCB Decision Points GMCB Decision Points New Information Since 10/10/2013 GMCB Measures Update Proposed Year 1 Commercial and Medicaid Shared Savings Program payment and reporting measures Yes Proposal for evaluating reporting measures Yes Proposed Gate and Ladder methodology to determine impact of payment measures on shared savings No 11/22/2013 3
Recommended Core Measure Set: Measure Use Terminology Payment Performance on these measures will be considered when calculating shared savings. Reporting ACOs will be required to report on these measures. Performance on these measures will be not be considered when calculating shared savings; ACO submission of the clinical data-based reporting measures may be considered when calculating shared savings. Pending Measures that are included in the core measure set but are not presently required to be reported. Pending measures are considered of importance to the ACO model, but are not required for initial reporting for one of the following reasons: target population not presently included, lack of availability of clinical or other required data, lack of sufficient baseline data, lack of clear or widely accepted specifications, or overly burdensome to collect. 11/22/2013 4
Recommended Year 1 Payment Measures (Claims data) Commercial and Medicaid Shared Savings Programs: All-Cause Readmission Adolescent Well-Care Visits Follow-Up After Hospitalization for Mental Illness (7-day) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis Chlamydia Screening in Women Cholesterol Management for Patients with Cardiovascular Disease (LDL Screening)* Medicaid Shared Savings Program: Developmental Screening in First 3 Years of Life *Related to Medicare Shared Savings Program Measure 5
Recommended Year 1 Reporting Measures (Claims data) Commercial and Medicaid Shared Savings Programs: Ambulatory Sensitive Conditions Admissions: COPD or Asthma in Older Adults* Breast Cancer Screening* Rate of Hospitalization for Ambulatory Care-Sensitive Conditions: PQI Composite Appropriate Testing for Children with Pharyngitis *Medicare Shared Savings Program Measure 11/22/2013 6
Recommended Year 1 Reporting Measures (Clinical Data) Commercial and Medicaid Shared Savings Programs: Adult BMI Screening and Follow-Up* Screening for Clinical Depression and Follow-Up Plan* Colorectal Cancer Screening* Diabetes Composite HbA1c control* LDL control* High blood pressure control* Tobacco non-use* Daily aspirin or anti-platelet medication* Diabetes HbA1c Poor Control* Childhood Immunization Status Pediatric Weight Assessment and Counseling *Medicare Shared Savings Program Measure 11/22/2013 7
Recommended Year 1 Reporting Measures (Survey Data) Patient Experience Survey Composite Measures (using same survey fielded by about 70 Blueprint primary care practices): Access to Care Communication Shared Decision-Making Self-Management Support Comprehensiveness Office Staff Information Coordination of Care Specialist Care 11/22/2013 8
New Information: Year 1 Commercial and Medicaid Shared Savings Program Payment and Reporting Measures The Depression Screening by 18 Years of Age was removed from the Medicaid Shared Savings Program Year 1 Payment Measures. Medicaid claims analysis revealed that providers are not using this code and that data collected on the measure would be inaccurate. The Quality and Performance Measures Work Group was informed that this measure could not be reported on accurately. Screening for Clinical Depression and Follow-Up Plan for persons 12+ is a Year 1 Reporting Measure and MSSP Measure. 11/22/2013 9
New Information: Proposal for Evaluation of Reporting Measures Proposal from VHCIP Quality and Performance Measures Work Group if measure set not substantively changed; supported by Core Team: ACO will make good faith effort to submit all reporting measures completely and in timely manner. Reporting will include analysis of barriers and costs to reporting, and plan to mitigate barriers. GMCB will provide guidelines for content and format of analysis and plan. Failure to report will have no financial consequences in Year 1 if ACO makes good faith effort to report all measures. Recommendations for Years 2 and 3 will be made by Work Group to Core Team and GMCB after considering barriers and costs identified during Year 1. 11/22/2013 10
Impact of Payment Measures: Commercial Commercial Gate and Ladder Approach: Compare each payment measure to national benchmark and assign 1, 2 or 3 points based on whether the ACO is at the national 25 th, 50 th or 75 th percentile. If ACO does not achieve at least 55% of maximum available points across all payment measures, it is not eligible for any shared savings ( quality gate ). In proposed commercial SSP quality ladder, ACO earns: 75% of potential savings for achieving 55% of available points, 85% of potential savings for achieving 65% of available points, 95% of potential savings for achieving 75% of available points. 11/22/2013 11
Commercial Shared Savings Program Ladder (proposed) Percentage of Percentage of available points earned savings 55% 75% 60% 80% 65% 85% 70% 90% 75% 95% 80% 100% 11/22/2013 12
Impact of Payment Measures: Medicaid Medicaid Gate and Ladder Approach: For most measures, compare each payment measure to national benchmark and assign 1, 2 or 3 points based on whether ACO is at national 25 th, 50 th or 75 th percentile. For two measures without national Medicaid benchmark (All-Cause Readmission and Developmental Screening), compare each payment measure to VT Medicaid benchmark, and assign 0, 2 or 3 points based on whether ACO performance declines, stays the same, or improves relative to benchmark. If ACO does not achieve at least 35% of maximum available points across all payment measures, it is not eligible for any shared savings ( quality gate ). In proposed commercial SSP quality ladder, ACO earns: 75% of potential savings for achieving 35% of available points, 85% of potential savings for achieving 45% of available points, 95% of potential savings for achieving 55% of available points. 11/22/2013 13
Medicaid Shared Savings Program Ladder (proposed) Percentage of available points Percentage of earned savings 35% 75% 40% 80% 45% 85% 50% 90% 55% 95% 60% 100% 11/22/2013 14
GMCB Decision Points and VCHIP Core Team Recommendations GMCB Decision Points Proposed Year 1 Commercial and Medicaid Shared Savings Program payment and reporting measures VCHIP Core Team Recommendation Adopt, with the caveat that the VHCIP Quality and Performance Measures Work Group explores adding a substance abuse screening measure to the Payment and Reporting Measure Set Proposal for evaluating reporting measures Adopt Proposed Gate and Ladder methodology to determine impact of payment measures on shared savings Adopt 11/22/2013 15
Work Group Process Over the course of nine months (January 2013- October 2013), the multi-stakeholder ACO Measures Work Group engaged in an intensive and inclusive process. The Work Group met approximately every two weeks to identify measures and recommend the impact of the selected measures on payment. 11/22/2013 16
Work Group Process (continued) Work Group members: Created crosswalk of over 200 measures from numerous measure sets, including the Medicare Shared Savings Program measure set Identified priority measures for consideration Focused on measures in various domains, with national specifications, with benchmarks, and with opportunities for improvement Eliminated measures through application of agreed-upon criteria and extensive discussion Expressed support for and concerns about measures Compromised Expressed widespread support, but not unanimity (see comments) 11/22/2013 17